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Full text of "United States Navy Medical News Letter Vol. 26, No. 9, 4 November 1955"

NavMed 369 

— __ :\\— VV ... V . 




Editor - Captain L. B. Marshall, MC, USN (RET) 



Vol. 26 Friday, 4 November 1955 No. 9 



TABLE OF CONTENTS 

Graduate Training in Navy Hospitals • 2 

SPECIAL NOTICE 3 

Construction of Cardioscope and Cardiac Stimulator 5 

Pyogenic Infections 7 

Complications and Postoperative Care after Tracheotomy 10 

Subdiaphragmatic Fundusectomy in Gastric Surgery 13 

Primary Reticulum -Cell Sarcoma of Bone , 14 

Hypothermia in Surgery 16 

Trigeminal Neuralgia 18 

Primary Carcinoma of the Ureter 20 

Krukenberg Tumors: Diagnostic Problem 21 

Deferment of Professional Examinations 24 

New Postgraduate Course Offered to Navy Medical Officers 24 

From the Note Book 25 

"Good Leadership" 27 

Information about MD Personnel and Activities (BuMed Inst. 5720. 2A) _ 28 

Physical Disability or Military Unfitness {BuMed Inst. 1910. 2A) 28 

MEDICAL RESERVE SECTION 

Naval Reserve Officer Schools 29 

PREVENTIVE MEDICINE SECTION 

Influenza Vaccination - 1955 31 

Influenza Vaccine Variation ; 32 

Effectiveness of Polio Vaccine 33 

JP-4 Jet Fuel in Eyes 35 

Potable Water in Ships' Tanks 36 

Ice Sanitation 37 

Comparative Vascular Pathology of Occupation Chest Diseases 38 

Value of Lung Biopsy in Diagnosing Occupational Pulmonary Diseases m 39 

Safety Goggles Prove Worth 40 



2 



Medical News Letter, Vol. 26, No. 9 



Graduate Training in Navy Hospitals 



1 Applications for assignment to residency training duty are desired 
from Regular medical officers and those Reserve medical officers who have 
completed their obligated service under the Universal Military Training and 
Service Act, as amended. The chart below lists those Navy hospitals which 
currently have vacancies at the first year level, and the specialties in which 
these vacancies exist. Vacancies are also available at other than first 
year levels. Information concerning non-first year appointments may be 
obtained by correspondence addressed to the Chief of the Bureau of Medicine 
and Surgery. 

2 Applications for the below first year level appointments will be accepted 
from now until 30 January 1956. 

3 A limited number of vacancies in General Surgery are now available to 
qualified Reserve officers. 

4 Letters of application for first year assignments should be forwarded 
via official channels to the Chief of the Bureau of Medicine and Surgery, 
and should include an obligated service agreement prepared in accordance 
with the provisions of BuMed Instruction 1520, 7. 




Anesthesia 


X 


X 


X 










General Practice 




X 






X 






Internal Medicine 




X 




X 






X 


Neurology 


X 






X 








Orthopedics 


X 


X 






X 






Otolaryngology 


X 






X 




X 




Pathology 


X 




X 








X 


Pediatric s 






X 










Psyc hiatry 


X 




X 


X 








Radiology 


X 


X 




X 




X 




Surgery 










X 


X 


X 


Urology 














X 


Cardio-Vascular Diseases 


X 













* * # # # ijc 



Medical News Letter, Vol. 26, No. 9 3 

SPECIAL NOTICE 

TO ALL ADDRESSEES (EXCEPT U. S. Navy and Naval Reserve 
personnel on ACTIVE DUTY and U. S. Navy Ships and Stations) . 

Existing regulations require that all Bureau and office mailing lists 
be checked and circularized at least once each year in order to eliminate 
erroneous and duplicate mailings. 

It is, therefore, requested that EACH RECIPIENT of the U. S. Navy 
Medical News Letter (EXCEPT U.S. Navy and Naval Reserve personnel 
on ACTIVE DUTY, and U. S. Navy Ships and Stations) fill in and forward 
immediately the form appearing below if continuation on the distribution 
list is desired. 

Failure to reply to the address given on the form by 15 December 
1955 will automatically cause your name to be removed from the files. 
Only one (1) answer is necessary. Please state the branch of the Armed 
Forces (if any) and whether Regular, Reserve, or Retired. Also, please 
write legibly. If names and addresses cannot be deciphered, it is impos- 
sible to compare them with the addressograph plates. 

Editor 



(detach here) 
Chief, Bureau of Medicine and Surgery 

Navy Department, Potomac Annex (date) 
Washington 25, D. C. 

I wish to continue to receive the U. S. Navy Medical News Letter. 

Name 
or 

Activity Ret 

or (print or type, last name first) (rank, service, corps) 
Civilian Status 



Addres s 

(number) (street) 
City Zone State 



(Signature) 

(Please print clearly. Only one answer is necessary. ) 



Medical News Letter, Vol. 26, No. 9 



5 



Policy 

The U. S. Navy Medical News Letter is basically an official Medical 
Department publication inviting the attention of officers of the Medical De- 
partment of the Regular Navy and Naval Reserve to timely up-to-date items 
of official and professional interest relative to medicine, dentistry, and 
allied sciences. The amount of information used is only that necessary to 
inform adequately officers of the Medical Department of the existence and 
source of such information. The items used are neither intended to be nor 
susceptible to use by any officer as a substitute for any item or article in 
its original form. All readers of the News Letter are urged to obtain the 
original of those items of particular interest to the individual. 

>}c ?fr sfc ?fr iQr ifc 

Notic e 



Due to the critical shortage of medical officers, the Chief, Bureau 
of Medicine and Surgery, has recommended, and the Chief of Naval Person- 
nel has concurred, that Reserve medical officers now on active duty who 
desire to submit requests for extension of their active duty for a period 
of three months or more will be given favorable consideration. 

4 >fc 4 $ 4 

Development and Construction of Cardioscope 
and Cardiac Stimulator, Using Standard 
Navy Supply Table Items 

Oscilloscopes can be used profitably in many aspects of clinical as 
well as research medicine. Utilization of these instruments is limited by 
virtue of the expense of existing commercially available models or by the 
relatively advanced electronics involved in the construction of instruments 
suitable for recording biological phenomenon. A partial solution of this 
problem of expense and electronic knowledge is offered. 

The problem of constructing a Cardioscope was attacked along the 
following lines: The Oscilloscope should be of a standard design and known 
construction. The Dumont Model Z08 or 208-B was selected, for it is widely 
used by both civilian and military. The conversion of certain existing Oscil- 
loscopes is cheaper and requires less time than to design and/or build an 
Oscilloscope for this purpose. 

A conversion unit was designed so that the electrocardiogram can be 
viewed on the Oscilloscope at an acceptable, controlable, and easy to ana- 
lyze rate. The conversion unit accomplishes two major things: 



6 



Medical News Letter, Vol. 26, No. 9 



1 Provides controlable horizontal sweep on the Oscilloscope 
at a rate sufficient to view cardiac action. 

2 Provides a means of connecting the modified Oscilloscope to 
the electrocardiograph machine without disturbing the normal electro- 
cardiogram, either when recorded on the electrocardiograph machine or 
when presented on the modified Oscilloscope. 

If explosion proof is desired for use in operating room, the entire 
modified Oscilloscope can be placed in an air tight metal container with 
cables for energizing the cardioscope and to feed the electrocardiogram 
intelligence from the electrocardiograph machine to the modified Oscillo- 
scope. If explosion proof is not required, the components required to 
fulfill items 1 and 2 may be placed in any reasonable container and the size 
should not exceed approximately one -third the total size of a normal com- 
mercial Oscilloscope. 

The total cost of the conversion unit is approximately $60. 00. If 
purchased, approximate cost of the Oscilloscope, $300. 00 new, $150,00 
used. However, all items concerned are available through standard Navy 
supply systems. 

The Oscilloscope, when modified and used with the electrocardio- 
graph machine, then becomes a "Cardioscope. " The device has been 
successfully used by both the surgeon and anesthetist as a continuous 
monitor of cardiac action. If desired, a permanent record can be made 
with the electrocardiograph machine while viewing any cardiac phase on 
the cardioscope. A foot switch has been devised, enabling the viewer to 
operate the electrocardiogram at a remote location. The cardioscope has 
also been of value where classroom instruction in cardiology and electro- 
cardiography has been in progress. 

The uses of this device are many, ranging from patients with Stokes - 
Adams syncope to the facilitation of recording a wide variety of biological 
phenomena. However, such is not the primary purpose of this work. It 
is the desire that this development will aid in bringing the Oscilloscope into 
a proper place in medicine to that of a very facile recorder of many uses. 

The problem of a cardiac stimulator has been attacked with the object 
of producing a workable device at a minimum of cost. A number of circuits 
have been devised with varying results from each. 

A completed model, involving a blocking Oscillator and utilizing com- 
ponent parts available through standard Navy supply systems, has been devel- 
oped. The circuit is not complex and can be used with a minimum of 
electronic background. 

The rate of stimulation is controlable from approximately 30-150 
pulses per minute. The wave shape at the output from the stimulator is 



Medical News Letter, Vol. 26, No. 9 



7 



basically rectangular and is variable in amplitude. Rate of pulsing can be 
observed by the use of a bulb included as a part of the stimulator. 

Output from the stimulator is applied to the body by use of two 21- 
gauge syringe needles inserted subcutaneously. Connection is made to the 
needles by the use of electronic connectors and a cable feeding energy from 
the stimulator. 

The stimulator lends itself very well for use with the Cardio scope, 
i. e. , it is possible to continuously monitor cardiac action with or without 
stimulation. 

(Captain Victor G. Colvin, MC USN, Chief of Medicine, and Lieutenant 
George Sutton, MC USNR, Head of the Heart Station, both of the Great Lakes 
Naval Hospital, supervised the ingenious conversion which was carried out 
by Chief Electronics Technician Wayne E. Connor, USN. ) 

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Pyogenic Infections 



The therapy of acute and chronic pyogenic infections of bones and 
joints is still beset with inadequate results, due in many instances to fre- 
» quently excessive dependence upon antibiotic drugs as a sole agent in the 
treatment of these lesions. It is true that, as a result of the use of the 
various antibiotics during the past decade, deaths from acute pyogenic 
infections have been diminished almost to the vanishing point and morbidity 
has been strikingly reduced. Nevertheless, there are a number of poor 
results that warrant attention and study. 

With respect to the therapy of pyogenic infections, it is fundamental 
that one keep uppermost in mind the well established concept that the acute 
and at times the chronic lesion, presents a complicated symptom complex 
which is the result of a varying proportion of the two components of the 
disease, namely, the systemic disease incidental to bacteremia and tox- 
emia and the local disease, be it suppurative arthritis, an osteomyelitic 
lesion or even a soft tissue abscess. Sufficient evidence exists that the 
systemic component of the disease can be obviated, provided the offending 
micro-organism is sensitive to a properly chosen and adequately adminis- 
tered antibiotic, and the toxemia is not overwhelming because pre -formed 
toxins are not influenced by antibiotics and must, therefore, be dealt with 
by the patient's defensive mechanisms. In contrast to the foregoing com- 
ments, it is just as clear that under similar circumstances the local 
component of the disease, if it is acute, may or may not be eliminated; 
and if it is chronic, antibiotic therapy alone will rarely if ever eradicate 
the disease. This variation in response to antibiotic therapy is due to the 
character of the pyogenic lesion. 



8 



Medical News Letter, Vol, 26, No. 9 



The acute hematogenous osteomyelitic lesion arises as a local 
inflammatory process during the course of a blood-borne, bacterial in- 
vasion and in response to the rapid multiplication of the micro-organisms 
and the production of exotoxins, leukocidins, hemolysins, and spreading 
factors, suppuration and abscess formation develop. A walling-off process 
sets in early in the form of peripheral thrombophlebitis and thromboarter- 
itis, while the central area of the- focus undergoes necrosis and suppuration. 
An additional important consideration in this process is that the abscess 
develops in rigid-walled surroundings and the resultant accumulation of 
pus under pressure aids in the growth of the lesion by interference with 
the blood supply in the adjacent metaphyseal and subperiosteal areas. 

When these phenomena — peripheral thromboarteritis, thrombo- 
phlebitis, and the avascularity arising from the pressure of the growing 
abscess — are viewed in the light of antibiotic therapy, and for that matter, 
in the light of chemotherapy or serotherapy, it becomes readily evident 
that these therapies must fail because of the inability of the blood stream 
to deliver the therapeutic agents into the focus of disease so as to make 
them effective,, In view of these considerations, the mere administration 
of antibiotics, no matter how well chosen or how well administered, will 
not be effective in the eradication of the lesion once it has become suffic- 
iently well developed. On the other hand, very early administration of 
antibiotics before the full development of the aforedesc ribed phenomena 
has been reached, will result in the prevention or abortion of these lesions, 
thus, accounting for the present-day decrease in the frequency of acute 
hematogenous lesions and their subsidence during the early stages of the 
disease. 

Therefore, it follows that rational treatment of the acute hematog- 
enous lesion should provide for the administration of a suitable antibiotic 
at the earliest possible moment. Subsidence of the systemic manifesta- 
tions of the disease should not lull the medical attendant into the belief 
that the local lesion also is being effectively overcome unless the local 
signs and symptoms likewise subside. Persistence of local pain, tender- 
ness, and swelling, notwithstanding the subsidence of temperature elevation 
and improvement of the general conditions, warrant surgical intervention 
in a matter of days after the onset of the lesion rather than weeks. 

One should not await roentgenographic changes before surgical inter- 
vention is undertaken in conjunction with antibiotic therapy. The operation 
should be performed under tourniquet control when possible and should 
consist of an incision along anatomic planes and decompression of the bone 
lesion regardless of whether or not pus is encountered in the soft tissues 
or subperiosteally. Excessive decortication or curettement of the focus 
should not be done. The focus should be thoroughly flooded with physio- 
logic solution of sodium chloride containing a high concentration of the 
antibiotic as it is closed firmly with several layers of sutures, without 



Medical News Letter, Vol. 26, No. 9 



9 



any drainage whatsoever. Immobilization is obtained by the use of a com- 
pression bandage of sheet wadding, flannel, and adhesive tape. The wound 
is not disturbed until the tenth postoperative day, at which time it will be 
found to have healed per primam. Antibiotic therapy is usually continued 
for a minimum of four weeks after the operation. 

Postoperative roentgen studies will reveal the gradual obliteration 
of the surgically created defect with diminishing evidence of disease activity. 
Eventually, the bone will present a completely normal appearance. The 
clinical recovery is just as thorough. Only under such circumstances can 
one feel assured that the lesion has been eradicated. 

The limitations of this article do not permit the presentation of statis- 
tics or case reports. Suffice it to say that, since 1944, when the author 
resorted to the use of primary closure without drainage of extensively 
saucerized wounds under antibiotic control, he has had a high proportion 
of cases of healing by primary intention — often under trying circumstances — 
of a large number of osteomyelitic lesions. Many of these lesions were 
extensive; some were multiple and of long duration with histories of many 
recurrences and exacerbations. Most commonly, failure of healing by 
primary intention was due to inadequate excision of the bone or soft tissue 
in proportion to the nature and extent of the lesion or inadequacy of the 
surgical technique. Many of these failures were anticipated because of the 
probable impossibility of a sufficiently thorough excision. These procedures 
were, nevertheless, undertaken with the hope that an amputation could be 
avoided. Other failures of healing by primary intention arose from a break- 
down of the skin coverage. Subsequent skin plastic procedures of skin 
grafts were, therefore, necessary to bring about the desired results. 

All of these cases have been kept under close follow-up observation. 
The author is, therefore, in a position to state that the rate of recurrence 
is much lower than that reported as following other methods of treatment. 
Some recurrences were anticipated because of the inadequacies of the 
surgical procedures. Nevertheless, the over-all results are so gratifying 
that the surgical maxim, "once osteomyelitis, always osteomyelitis, " may 
eventually become a thing of the past. 

The therapy of acute and chronic pyogenic infections of joints has 
much in common with the therapy of acute and chronic osteomyelitis. The 
variations in the therapeutic approach are dependent upon the variations 
in the pathomechanical nature of these lesions. Acute, hematogenous 
pyogenic arthritis is more amenable to antibiotic therapy without the surg- 
ical approach because the developing abscess does not have the rigid con- 
fines of the bony walls observed in its osteomyelitic analogue, and the 
threat of rapid spread of the lesion because of aseptic necrosis incidental 
to obliteration of blood supply is nonexistent. Furthermore, the absorp- 
tive capacities of joint synovial tissues and their blood stream communica- 
tions are much more extensive than in the osteomyelitic lesion. In view 



10 



Medical News Letter, Vol. 26, No. 9 



of these variations, early systemic administration of a well-chosen anti- 
biotic and local therapy by means of repeated aspirations of the joint and 
instillations of physiologic solution of sodium chloride, containing a high 
concentration of the antibiotic, will resolve the lesion. Failure of such 
resolution, as indicated by the persistent presence of the offending micro- 
organisms within the aspirated fluid, will necessitate the surgical excision 
of all infected tissues and the abscess wall. This should not be deferred 
unduly lest joint function be lost. It should be performed under a systemic 
as well as a local antibiotic "umbrella, " and the surgical wound should be 
closed without drainage. 

The author outlines the rationale of the therapy of acute, postacute , 
and chronic pyogenic lesions of bones and joints by the use of antibiotics, 
surgical intervention, and primary closure of the surgically formed wounds 
based upon the pathomechanic s of the various lesions. Great emphasis is 
placed upon the effectiveness of a properly chosen antibiotic during the early 
phases of the lesion before the walling-off process has been fully established. 
Greater emphasis is placed upon the ineffectiveness of a properly chosen 
antibiotic when used as the sole agent of therapy in the presence of a fully 
developed acute or chronic pyogenic lesion by reason of the walling-off 
process which prevents the delivery of the drug via the blood stream into 
the disease focus. Stress is also placed upon prevention of the exogenous 
type of pyogenic lesions of bones and joints by timely use of the antibiotics 
in conjunction with various surgical procedures. (Buchman, J. , The Therapy 
of Pyogenic Infections of Bones and Joints: J. Internat. Coll. Surgeons, 
XXIV : 300-307, September 1955) 

Complications and Postoperative Care 
after Tracheotomy 



Because there has been an increase in the indications for tracheotomy, 
objective analysis of the available facts concerning complications should 
be made. Tracheotomy is employed in a large number of conditions; and 
while the question of its necessity in such a varied list may be raised, it 
has proved to be the difference between survival and death in many cases. 
Procrastination and delay in performing the operation is hazardous to 
the patient and leads to more serious complications than any that may 
develop from the operation itself. In some instances, it has been done 
without sufficient reason and the patient probably would have recovered 
anyway, although it may have hastened this development. In still other 
cases, nothing that one could do would relieve or cure the patient, and in 
this type of case no benefit resulted. 



Medical News Letter, Vol. 26, No. 9 



11 



It is by no means clear just how much the trauma and short-circuiting 
of the air current by tracheotomy with its indwelling tube affects inflam- 
matory exudate and causes dryness and crusting of the tracheobronchial 
secretions. The drying effect can be overcome to a large extent by proper 
humidification of the inspired air, and the crusting can be minimized by 
judicious suction after irrigation with saline solution. The use of deter- 
gent agents and proteolytic enzymes provides some help, but to a lower 
degree. 

Tracheotomy is a relatively simple procedure and the complications 
that develop are generally due to faulty surgical technique. Although the 
risks of the operative procedure are negligible, the postoperative sequelae 
may produce disability with subsequent long periods of treatment before 
recovery. 

Severe and critical hemorrhage after tracheotomy has been reported 
but this complication is rarely encountered except from actual tumor in- 
vasion of the trachea with erosion into a large vessel. In infants, the 
trachea is soft and of such small caliber that unguarded incision of the 
anterior wall may result in cutting the posterior tracheal wall. Atelectasis 
and post-tracheotomy pneumonitis can be prevented by keeping the airway 
free from secretion while simultaneous antibiotic therapy reduces the mor- 
bidity and mortality. 

The most frequent complications are mediastinal emphysema and 
pneumothorax. While these occur often, they are usually not present to 
a de L :ee to cause concern. Pneumothorax is probably commoner than 
is generally believed and is found only on routine chest roentgenograms 
in many instances. Several authorities have explained the mediastinal 
emphysema on the basis of the indrawing of air into the mediastinum after 
incision of the pretracheal fascia by the high negative intrathoracic pres- 
sure from excessive respiratory efforts. 

The most difficult complication to overcome and one which can be 
most easily prevented is that of stenosis at the site of the tracheotomy. 
When this occurs, there is delay in decannulation. It is particularly 
prone to occur in infants and young children whose tracheal rings are soft 
and can be easily compressed. After stenosis develops, it is often neces- 
sary to dilate the trachea for a long period of time and remove granulations 
from the airway before the patient can be decannulized. In other instances, 
the child must grow up around the tracheotomy tube so that the lumen is 
increased sufficiently to, overcome the stenosis. 

The proper size of the tracheotomy tube for the size of the patient 
is an important consideration. It should rest comfortably in the trachea 
and not occupy the entire lumen. Granulation tissue oftentimes forms at 
the site of the opening but this is more likely to occur when a large tube 
is inserted in the trachea rather than a tube of appropriate size for the 



12 



Medical News Letter, Vol. 26, No. 9 



patient. At times, granulations on the posterior tracheal wall form from 
trauma of the distal end of the tracheotomy tube. 

The after-care of tracheotomized patients needs to be clarified for 
both the nursing and the general medical profession. The establishment 
of a tracheotomy is only a means to an end and the operation itself does 
not cure the patient. It affords an accessory airway which must be kept 
free of secretion in order to function and provides a means of entering the 
lower respiratory tract to remove obstruction when it develops. It may 
seem elementary to mention the fact of daily changing of the tracheotomy 
tube. All too frequently, infants are admitted to the hospital with a tracheo- 
tomy tube in place which has not been changed for 10 to 14 days. 

When visiting a tracheotomized case, it is not infrequent to find the 
youngster in marked dyspnea, and when the patient is examined, crusting 
around the tracheotomy tube, with no air getting in or out of the lungs, is 
found. Simple cleansing of the inner cannula at stated intervals will relieve 
this condition. Generally, nurses are rather timid in aspirating a patient 
with a tracheotomy and introduce the aspirator only to the end of the trach- 
eotomy tube. While this cleans the tube, it does not aid in clearing the 
lower respiratory passages. A small soft-rubber catheter introduced 
down to the carina and commonly into one or the other or both main bronchi 
is needed in many instances. It should be mentioned that frequently catheter 
aspiration clears only one bronchus, usually the right, because the flexible 
tube follows the straight route and aspiration through the bronchoscope 
under direct vision must be used in addition. This has been particularly 
evident in postoperative tracheotomized thoracic surgical cases when 
broncho scopic examination revealed retention of secretion in one or the 
other bronchus immediately after thorough catheter suction via tracheo- 
tomy had been carried out. 

Crusting develops frequently, making removal of secretions difficult, 
but it can be facilitated by the introduction of several cubic centimeters of 
isotonic saline solution into the trachea several seconds before aspiration. 
Proper humidification and nebulization of the inspired moisture minimize 
this complication. Oxygen itself has a drying effect upon the mucosa of 
the tracheobronchial tree and when employed should be used with some 
form of humidification to overcome the dryness. 

Considering the advantages and disadvantages of tracheotomy, the 
former far outweigh the latter. When it is realized that the complications 
arise from faulty technique in the majority of cases, it would seem that 
this could be eliminated altogether, thus allowing for greater usefulness 
of this important operation. {Putney, F. J. , Complications and Postoperative 
Care after Tracheotomy: Arch. Otolaryng. , 62: 272-276, September 1955) 

$ jj: j|s >Jc j}: !{e 



Medical News Letter, Vol. 26, No. 9 
Subdiaphragmatic Fundusectomy in Gastric Surgery 



13 



The technique for subdiaphragmatic fundusectomy has been worked 
out by the authors for reasons which are set out in this article. This is 
a method of resection of the upper portion of the stomach by which a re- 
moval of part of the fundus and a subdiaphragmatic union of the intra- 
abdominal stump of the esophagus with the remainder of the stomach can 
be carried out without much risk. 

The indications for fundusectomy, in the opinion of the authors, are 
all isolated pathologic processes in the upper third of the stomach. The 
operation is indicated, therefore, principally for the radical treatment of 
the subcardiac, large, callous, hemorrhagic and possibly malignant ulcers 
and for carcinomas of the fundus region which do not involve the cardia 
and the left gastric artery. 

Pre-eminently suitable for fundusectomy are the localized carci- 
nomas situated in the region of the greater curvature of the fundus because 
the lymph drainage of this region goes to the hilum of the spleen. The spleen 
as well as parts of the tail of the pancreas, in certain circumstances may be 
removed without difficulty during fundusectomy For the carcinomas which 
are situated on the lesser curvature of the fundus, fundusectomy may be 
employed only in exceptional cases because the regional metastasis that 
occurs in the lymph drainage area of the celiac artery is generally more 
extensive and, thus, requires an abdominothoracic resection. 

For the success of the subdiaphragmatic fundusectomy, two technical 
requirements must be absolutely observed. 

1 Preservation of the esophageal branches of the left gastric 
artery which together with the ramifications of the inferior phrenic 
artery serve the intra-abdominal esophagus stump. This preserva- 
tion is of the utmost importance for the success of the high subdia- 
phragmatic anastomosis which is performed. 

2 The craniocaudal direction of resection by means of which at 
the beginning of the operation it is possible to judge with confidence 
the extent of the pathologic process. By means of biopsy speci- 
mens of the intra-abdominal stump and the left gastric artery at 
the division by the esophageal branches, it is decided whether a 
partial resection of the upper part of the stomach by fundusec- 
tomy is advisable. 

By means of the technique of subdiaphragmatic fundusectomy, a gap 
has been closed in the practice of gastric surgery. By adhering to the 
resection technique given in this article, esophagogastrostomy which has 
for long been feared in numerous surgical centers can be carried out from 



14 



Medical News Letter, Vol. 26, No. 9 



a purely abdominal approach without too great a risk. Therefore, it is 
possible to remove isolated pathologic processes in the fundus region of 
the stomach without removing the whole stomach as has previously been 
usual. 

Total gastrectomy is such a severely mutilating intervention that 
it should be used only in cases of dire necessity. The choice of operative 
technique should be made in every individual case so that the optimal 
degree of radical resection is combined with the least possible loss of 
gastric function. 

The development of an operative technique for partial resection of 
the upper section of the stomach is now one of the most important prob- 
lems of gastric surgery. The development of subdiaphragmatic fundu- 
sectomy has made a contribution in this respect; the technique is described 
by the authors. 

Follow-up studies of iron absorption after fundusectomy have shown 
that in both experimental animals and human beings dysfunction of iron 
absorption does not appear. This is in contrast to the two-thirds resection 
operation. Fundusectomy is superior to the two-thirds resection operation 
in respect of postoperative iron absorption function. 

The proteolytic capacity of the fundus ectomized stomach is not 
significantly limited. This is increased by the addition of the unaltered 
tryptic capacity of the duodenal juice so that an undisturbed total proteolytic 
action remains. 

According to the authors' experience, fundusectomy is suitable for 
the removal of local, limited neoplasms in the region of the fundus. It is, 
above all, recommended for the radical treatment of subcardiac callous 
ulcers which are suspected of malignancy. {Holle, F. , Heinrich, G, , 
Subdiaphragmatic Fundusectomy in Gastric Surgery: Surg. Gynec. & Obst. , 
101 : 385-394, October 1955) 

****** 

Primary Reticulum -Cell Sarcoma of Bone 

Primary reticulum-cell sarcoma of bone is a malignant tumor histo- 
logically indistinguishable from reticulum-cell sarcoma arising in other 
regions of the body. It originates at a single site in bone and, when 
metas + asis occurs, it is usually by way of the lymphatics. Pain and swel- 
ling are the chief symptoms, and characteristically there is lack of con- 
stitutional reaction. The prognosis is relatively good, the five-year survival 
rate approaching 50% following operation or proper irradiation. The impor- 
tance of distinguishing between this tumor and other similar but more 
malignant conditions, such as osteogenic sarcoma and Ewing's tumor, is 
apparent. 



Medical News Letter, Vol. 26, No. 9 



15 



In 22 of 33 cases, the origin was in long bones, and in 14 of these, 
in the lower extremities. It should be noted that in the generalized form 
of reticulum -cell sarcoma involvement of long bones is uncommon. 
Whereas, the skull is a frequent site of metastasis in the generalized 
disease, the 3 cases of Strange and de Lorimier, as described, are the 
only ones reported in which the disease was primary in the skull. Primary 
lesions in the mandible, however, are not rare. Both primary and metas- 
tatic forms of reticulum -cell sarcoma are seen in the vertebrae and pelvis. 

Twenty-five of the 33 patients were males, the male to female ratio 
being approximately 3 to 1. The youngest patient was 9 years of age and 
the oldest 67. The average age of all patients was 39. 3 years. Fifty 
percent were 40 years of age or less; only 4 patients were less than 20. 
In comparison, it should be noted that the generalized form of reticulum- 
cell sarcoma has its peak incidence in the sixth decade of life, and that 
Ewing's tumor most commonly occurs in childhood and adolescence. 

The chief symptoms were persistent pain and swelling, features 
common to the onset of any malignant bone tumor. Pain was present in all 
cases and with the exception of 2 cases was the initial symptom. Typically, 
the pain was intermittent at first, gradually becoming more severe and 
finally almost constant. 

Swelling at the site of the lesion was observed in 85% of the 33 cases. 
No other notable symptoms were described with the exception of disability 
resulting from joint involvement by the tumor, or cord symptoms from 
collapse of a vertebra. 

An important feature of the disease which has been emphasized by 
nearly all writers is the fact that general well-being of the patient is almost 
uniformly seen. This is in contradistinction to the chronic low-grade fever, 
fatigability, and loss of weight which are experienced by most patients 
with other types of malignant bone tumor, and by those with the generalized 
form of reticulum -cell sarcoma. This finding of well-being was noted in 
the majority of cases in the present series. 

In order to obtain as accurate an evaluation as possible of the roent- 
gen findings in primary reticulum -cell sarcoma, each roentgenogram was 
critically studied with regard to the following fundamental features: (1) 
location of the tumor in the involved bone, (2) destruction of bone, (3) reactive 
proliferation of bone, (4) cortical destruction, (5) cortical thickening, (6) 
periosteal reaction, (7) soft-tissue involvement, (8) soft-tissue calcification, 
and (9) pathologic fracture. The extent to which each of the foregoing changes 
(3 through 8} appeared on the roentgenograms was determined and expressed 
in one of the following terms: marked, moderate, minimal, or none. The 
roentgenologic features are illustrated. 

From the analysis, it is apparent that primary reticulum-cell sar- 
coma may be located anywhere in a given bone, but when occurring in the 
lower extremity, is more likely than not to originate near the knee joint. 



16 



Medical News Letter, Vol. 26, No. 9 



When seen in the upper extremity, the lesion frequently involves the 
proximal part of the humerus. 

On the basis of this series of cases, destruction of bone appears 
to be the chief roentgen feature. While it may vary considerably in extent, 
it commonly has an irregular distribution, giving the bone a mottled, patchy 
appearance. About half the time one may expect to see reactive prolifera- 
tion of bone, but this finding rarely overshadows the destructive component. 
Destruction of cortical bone is a nearly constant feature, but too, it is 
extremely variable in degree. Thickening of the cortex is seen in about 
one -fourth of the cases but is rarely extensive. Periosteal reaction occurs 
to a minimal or moderate degree in about half the cases and occasionally 
is a striking feature. Approximately three-fourths of the patients manifest 
soft-tissue involvement roentgenographically, and one-fifth of these have 
evidence of calcific changes in the periosseous component. Pathologic 
fractures are of frequent occurrence. 

While the roentgenologic appearance of this tumor varies to such an 
extent that it may not be regarded as characteristic, the radiologist fre- 
quently may suspect the diagnosis of reticulum -cell sarcoma and suggest 
it to the clinician. He must, however, keep in mind the fact that osteogenic 
sarcoma, Ewing's tumor, eosinophilic granuloma, and chronic osteomye- 
litis cannot always be excluded with certainty. (Wilson, T. W. , Pugh, D. G. , 
Primary Reticulum -Cell Sarcoma of Bone with Emphasis on Roentgen 
Aspects: Radiology, 65: 343-350, September 1955) 

****** 
Hypothermia in Surgery 



This report is concerned with an analysis of the authors' experience 
with the first 100 patients whom they subjected to hypothermia, a deliberate 
physiologic adventure, with particular reference to its dangers and limita- 
tions as well as to its potential and actual usefulness in the attainment of 
operative objectives. 

Because experimental interest has become widespread, seemingly 
contradictory physiologic data have been presented and, therefore, term- 
inology is important. The authors define general hypothermia as the 
physical state of an homothermic individual in whom the body temperature 
is below the normal range for that individual. For man, therefore, with 
a normal range of 36° C. to 37. 5° C. rectal temperature, any persistent 
temperature below 36° C would be accepted as representing a state of 
hypothermia. Obviously, the range of hypothermia is great. 

The authors believe that, because hypothermia appears to have 
serious inherent risks and if pursued far enough inevitably results in 
death, the major aim of experimental effort should be directed toward 



Medical News Letter, Vol. 26, No. 9 



17 



increasing their understanding of the relationship between the variables 
and the cardiac, circulatory, cerebral, hematologic, and metabolic 
tolerance to hypothermia; thus, deliberate control of such variables may 
be employed to increase the safety of the technique and expand its clinical 
utility. They believe also that a small beginning in this direction has been 
achieved. The present report describes their current thinking and practices 
in the effort to influence risk by the control of variables; how much remains 
to be elucidated will be evident. 

The prime indication for the use of hypothermia in this series has 
been the desire to perform an operation in a bloodless field during tempo- 
rary occlusion of the blood supply to or through the organ. Hypothermia 
was used as an agent to prolong the time -tolerance to ischemia and, thus, 
allow safe operating periods. That a low body temperature achieves this 
aim by its reduction in tissue metabolic rates has been clearly shown by 
many investigators and needs no elaboration. For this reason, all open 
intracardiac procedures and about half of the non-cardiac operations (cere- 
bral and aortic) were performed during hypothermia. 

A second indication has been to attempt to improve the operative 
risk in patients with congenital or acquired heart disease by achieving 
either better oxygenation of the patient {as in cyanotic cardiopathies) or 
slowing of the heart rate in severe tachycardia. In some instances, the 
authors were most pleased with the apparent effectiveness of hypothermia 
for this purpose. 

A third indication was to explore hypothermia as a method of achiev- 
ing hypotensive anesthesia in an effort to diminish operative blood loss 
without actual circulatory occlusion. A few patients with large visceral 
neoplasms were operated for this reason. However, the results were 
disappointing, in that, although operative hemorrhage was diminished, 
later ooze from unidentified vessels resulted in a total blood loss essen- 
tially undiminished. 

The fourth and final indication used in this series was also an anes- 
thetic one. Because hypothermia of sufficient degree is itself a potent 
anesthetic agent, it appeared possible that it might be less toxic to the 
individual than pharmacological agents, particularly under certain condi- 
tions. In patients who were facing prolonged and extensive procedures, 
or in whom there was hepato-cellular damage, cold might be less damaging 
than drugs. 

Experience with 100 patients undergoing 105 operative procedures 
during general hypothermia is presented and discussed. Of these, 59 had 
direct vision intracardiac procedures, 21 had closed cardiac operations, 
while 20 had operations unrelated to heart disease. The total mortality 
was 22, the hypothermic-operative mortality, 14. 

For achieving direct vision intracardiac operation, the technique 
is both effective and safe in congenital lesions which can be repaired through 



18 



Medical News Letter, Vol. 26, No. 9 



a right heart approach with occlusion times of 8 minutes or less at body- 
temperatures not lower than 26° C. The mortality rises sharply when 
these limits are exceeded. Extension of the technique to acquired lesions, 
or to those requiring left heart approaches, has not been explored. At 
present, the authors consider this the method of choice in the treatment 
of isolated valvular or infundibular pulmonary stenosis and of inter -atrial 
septal defect. 

As a technique for reduction of operative risk in patients with con- 
genital heart disease, characterized by deep cyanosis or by hypertrophied 
overactive hearts, the authors' impression was favorable. This technique 
may be less well tolerated or even non-beneficial in the presence of left 
heart strain. As a technique to allow temporary regional or organ ischemia 
to achieve a bloodless field, the method is both effective and quite safe. 

In the human, acute hypothermia above 26° C. , per se, appears to 
carry a very low risk provided many detailed precautions are observed. 
The prime cause of mortality is ventricular fibrillation and its sequellae. 
The risk of this complication exists primarily in patients with diseased 
hearts who undergo cardiac manipulation, and it rises progressively as 
more complicated, extensive, and prolonged operations on these hearts 
are attempted. 

General hypothermia appears to be of sufficient safety and value to 
warrant further clinical evaluation and continued use. (Swan, H. , et al. , 
Hypothermia in Surgery - Analysis of 100 Clinical Cases: Ann. Surg. , 
142 : 332-399, September 1955) 

****** 

Trigeminal Neuralgia 

Trigeminal neuralgia, or tic douloureux, presents one of the most 
constant and classic syndromes in all medicine. 

This syndrome is characterized by three features: (1) intermittent 
paroxysms of pain along the distribution of one or more divisions of the 
trigeminal nerve with complete freedom from the pain between paroxysms; 
(2) a unique "trigger mechanism" by which is meant that stimulation to the 
skin of the face or to the membranes of the mouth such as washing, shaving, 
drinking hot or cold liquids, eating rough foods, talking, or even smiling, 
will set off paroxysms of pain; and (3) a neurological examination with no 
abnormal findings. This unique triad is always produced by true trigemi- 
nal neuralgia and never by any other condition. 

The cause of trigeminal neuralgia remains a mystery. The most 
careful studies of neuralgic nerves have never revealed any structural 
basis for the pain. 



I 



Medical News Letter, Vol. 26, No. 9 



19 



The course of untreated trigeminal neuralgia is remarkably constant. 
There may be temporary remission but pain always returns and always in 
more severe form and wider distribution than before. There is no spon- 
taneous termination of the disease. 

There are three well-established methods for treating trigeminal 
neuralgia. The first is by the inhalation of trichloro ethylene, a highly 
volatile liquid closely related to chloroform. This will give relief to 5 
or 10% of the patients. 

The second standard method of treatment is by the injection of 95% 
alcohol directly into those divisions of the nerve that are giving rise to 
pain. This procedure is extremely painful and the relief afforded is only 
temporary. This relief lasts as a rule from 6 to 18 months after the first 
injection, but successive injections are always more difficult to accomplish 
and give shorter periods of relief; eventually, a time will come for each 
patient when alcohol will no longer relieve the pain. 

The third method, and the one now generally accepted, is the intra- 
cranial section of the sensory root of the nerve. This can be done above 
the tentorium through the temporal approach or below the tentorium through 
the suboccipital approach. Both methods have good points, but at the Neuro- 
logical Institute, the simpler temporal approach has proved to be satisfac- 
tory and is the method generally used. This operation can be performed 
entirely under local anesthesia or with the help of one of the new intra- 
venous barbiturates such as thiopental sodium. The mortality rate after 
operations is only a small fraction of 1% despite the fact that many patients 
are 60 to 75 years of age or older, and often are considerably debilitated. 
Also, the postoperative morbidity is slight, the patients being out of bed 
as a rule on the first or second postoperative day and out of the hospital 
by the end of 5 or 6 days. 

The relief of pain after sectioning of the nerve is immediate, com- 
plete, and permanent in all instances of true trigeminal neuralgia. The 
principal objection to the procedure is that the skin and mucous membrane, 
supplied by the divided nerve fibers, are permanently anesthetized after 
the operation, but the exchange of pain for anesthesia is as a rule easily 
accepted by patients who have been suffering with severe trigeminal neu- 
ralgia. Only in instances where operations have been performed ill- 
advisedly for facial pain which is not true trigeminal neuralgia, does this 
postoperative numbness of the face acquire importance. In such cases, 
the facial pain will not be relieved by the operation and the numbness will 
simply add a new complaint to the original one. 

Facial paralysis, which is often feared by the layman faced with an 
operation for relief of trigeminal neuralgia, is a rare complication. When 
it does develop, it is usually not until the second or third postoperative 
day and, hence, cannot be the result of direct trauma to the nerve during 



20 



Medical News Letter, Vol. 26, No. 9 



operation. The mechanism of this delayed palsyis not known. Fortunately, 
it is almost never permanent, spontaneous recovery usually taking place 
in a matter of weeks. 

During the past year or so, two new operative procedures have 
been proposed that are claimed to relieve trigeminal neuralgia without 
leaving the skin and mucous membranes anesthetized. These operations 
are designed to "decompress" the trigeminal nerve at some point along 
its course where it is thought to be constricted. In one operation, the 
opening in the tenorium, through which the sensory root passes, is 
enlarged. In the other, the foramens, rotundum, and ovale, through 
which the second and third divisions of the nerve leave the skull, are en- 
larged. Although hoping that the claims made for these new operations 
will prove to be true, most neurosurgeons question their validity and feel 
that judgment must be reserved for the time being. (Scarff, J. E. , Tri- 
geminal Neuralgia: J. Am. Dent. A., 51:406-408, October 1955) 

5p 5p 3^1 S}i 5p 

Primary Carcinoma of the Ureter 

Primary carcinoma of the ureter has always been considered a very 
rare disease but recent reports in the literature suggest that it should be 
changed from the rare to the infrequent class. The disease has appar- 
ently received little attention in the radiologic literature because the 
author has been able to discover only one reference in the radiologic jour- 
nals. All other references were discovered in urological, surgical, or 
cancer journals, or in non- specialized publications. Therefore, it might 
be of advantage to radiologists to become better acquainted with primary 
carcinoma of the ureter. 

Pathologically, primary cancer of the ureter is a carcinoma of the 
transitional type of epithelium found in other parts of the urinary tract 
such as the renal pelvis and the urinary bladder. The ureteral tumors 
can possess all the features of tumors in the renal pelvis and the urinary 
bladder. The neoplasms have a tendency to be multicentric in location 
and may be found widely separated in the urinary tract, but most often 
only localization is found. If situated low in the ureter, the tumor may 
grow downward and protrude into the bladder at the ureteral orifice so 
that it can be seen and biopsied cystoscopically. The tumor may be a 
solid pedunculated growth occluding the ureteral lumen, a sessile papillary 
carcinoma with invasion of the ureteral wall, or a diffuse papillary growth. 
The papillary growths can encircle the ureter to spread early, extensively, 
and quickly. The rate of growth frequently depends upon the degree of 
differentiation of the tumor. According to Soloway, metastases were 
found in 62% of reported cases; in order of frequency, these metastases 



Medical News Letter, Vol. 26, No. 9 



21 



occurred in regional and distant lymph nodes, the liver, lungs, bones, 
kidneys, adrenals, spleen, brain, pancreas, and skin. 

The tumor bleeds freely and causes varying degrees of ureteral ob- 
struction. Dilatation of the ureter above the tumor, and hydronephrosis 
are frequent complications. Some of the more invasive tumors have been 
known to produce perforation of the ureter. 

The tumors are found predominantly in the lower third of the right 
ureter in from 50 to 67% of cases, depending on the reporting author. Clin- 
ically, a symptomatic triad has been described as consisting of hematuria, 
pain, and a palpable abdominal mass. The most frequent symptom is that 
of bleeding which is often intermittent, ceases for no apparent reason only 
to recur, and is often painless, especially at the onset of the disease. The 
pain may be due either to the obstruction of the ureter with back pressure 
symptoms upon the upper urinary tract, or to direct invasion of the ureter. 
The abdominal mass is the distended hydronephrotic kidney. 

Cancer of the ureter was found in patients 22 to 89 years of age. The 
greatest number is seen in the sixth and seventh decades and in 65% of 
cases, the male sex was afflicted. 

The treatment of choice consists of a complete nephro-ur eterectomy, 
preferably with removal of a cuff of bladder at the ureterovesical junction. 
The average survival time is 21. 1 months. Preoperative and postoperative 
radiation therapy appear to be of no value. 

The diagnosis of primary carcinoma of the ureter may be suspected 
from the clinical history. The typical case may be pictured as in a man, 
60 years of age, with intermittent hematuria, pain in the flank of a con- 
tinuous nature and a palpable mass in the renal area. The ultimate diag- 
nosis, however, can be made much more probable by roentgenologic 
studies. 

The differential diagnosis to be considered is that of nonopaque cal- 
culi, blood clots, benign ureteral stricture, ureteritis cystica, and ureteral 
tuberculosis. (Savignac, E. M. , Primary Carcinoma of the Ureter: Am. 
J. Roentgenol. , 7_4: 628-634, October 1955) 

sftc njc sjs jjc sfts ifc 

Krukenberg Tumors: Diagnostic Problem 

The term, "Krukenberg tumor, " as used in this article, includes 
only those carcinomas of the ovary arising in the gastrointestinal tract 
and those signet-ring cell carcinomas primary in the ovary itself. 

The age distribution for 468 women with Krukenberg" s ovarian car- 
cinoma is illustrated. Most were of reprod\ictive age. The youngest was 
13 years old and the oldest was 81. These extremes, however, were 
uncommon. 



22 



Medical News Letter, Vol. 26, No. 9 



The average age of patients with the primary cancer in the stomach, 
colon, or rectum, was similar. Those with primary lesions in the gall- 
bladder or small intestine were, to the contrary, more often a decade 
older (fifth) than those with cancer of the stomach. 

Pain and anorexia were the commonest complaints given by women 
with metastatic ovarian neoplasms. Pain, if present, was generally local- 
ized to the epigastrium in the patients with primary gastric cancer. Fre- 
quently, it was associated with either heartburn or a feeling of fullness. 
Tumor was the next most frequent complaint. Usually, it was the ovarian 
neoplasm that was felt and not the gastric growth. Commonly, symptoms 
began insidiously and were either so mild, negligible, or overshadowed 
by the pelvic disease, that little if any attention was given to the gastro- 
intestinal disturbance. Hematemesis often was attributed incorrectly to 
a peptic ulcer. 

Nausea, anorexia, loss of weight, constipation, or abdominal dis- 
comfort were the symptoms usually given by patients with primary carci- 
noma of the colon, cecum, rectum, and appendix. Those with the primary 
growth in the duodenum, pancreas, or hepatic system ordinarily suffered 
with epigastric discomfort, nausea, or loss of weight, or all three. 

Anorexia, regardless of the location of the primary tumor, often 
antedated the correct diagnosis by several weeks or months. In the 
presence of pregnancy, it was generally attributed to hyperemesis gravi- 
darum. In other instances, pregnancy was wrongly suspected because of 
nausea and vomiting. 

Nearly 50% of the women with metastatic ovarian carcinoma of 
Krukenberg, where the duration of symptoms was known, had complaints 
less than 6 months, another 20% one to two years, and the remaining 
number, more than two years before consultation was obtained. This was 
true, regardless of the origin of the cancer. 

Twenty-six women with Krukenberg's metastatic ovarian carcinoma 
were either pregnant or had given birth recently. 

Detailed descriptions regarding the pathology of the Krukenberg 
tumors are available elsewhere. In this article, only the principal char- 
acteristics of the tumor are given. Grossly, this neoplasm is solid with 
an irregular smooth surface. Commonly, the cut section shows variegated 
areas — cystic, gelatinous, or hemorrhagic — intermingled with a firm to 
spongy framework. These cancers range from microscopic size to masses 
weighing several pounds. Four out of five are bilateral; the fifth is unilateral. 

Microscopically, the structure of the tumor may differ from one part 
to another. The stroma may be cellular, edematous, or myxomatous. 
Epithelial cells may be arranged in true or false clusters. Often there are 
typical signet-ring cells. These may appear in any type of mucin-producing 
carcinoma. Mucification, therefore, does not necessarily indicate that 
the tumor arose in the gastrointestinal tract. 



Medical News Letter, Vol. 26, No. 9 



23 



Metastases, determined by either exploratory laparotomy and/or 
post-mortem examination for patients with metastatic ovarian cancer, 
were most commonly found in the peritoneum, regional lymph nodes, 
mesentery, omentum, and pleura in the order named. In contrast, the 
substance of the liver was seldom involved. Generalized carcinomatosis 
was not common. Yet, occasional spread occurred to heart, bone marrow, 
brain, and skin. 

The procedures employed to arrive at a correct diagnosis, in addi- 
tion to a history and complete physical examination, are recorded for 237 
women. A correct diagnosis is defined as establishing the site of the 
primary tumor as well as the presence of a Krukenberg ovarian metas- 
tases. Even with laparotomy, a correct diagnosis was often unestablished. 
Reports, however, do not indicate how many surgeons palpated the other 
abdominal viscera at the time of exploring part of the abdomen or pelvis. 

The time interval between the diagnosis of the primary and secondary 
cancer or vice versa was available for 45 women. In two-thirds of them, 
there was an interval of 1 or more years compared to 1 to 12 months for 
the other third. 

This study shows that, when the triad of persistent, sometimes 
almost negligible dyspepsia, anorexia with epigastric discomfort, and 
firm adnexal tumors is found particularly in a woman of reproductive age, 
metastatic ovarian carcinoma with a primary neoplasm of the gastrointes- 
tinal tract should be included in the differential diagnosis. Repeated roent- 
genographs studies of the gastrointestinal tract, gastroscopy, occasionally 
bimanual examination under anesthesia, exploratory laparotomy, or a 
combination of these procedures is required to confirm the diagnosis and 
to ascertain the origin of the neoplasm. Roentgenographs study, if depended 
on alone, may be misleading. Occasionally, the primary site may not be 
found until a careful post-mortem examination is done. The diagnosis of 
metastatic ovarian carcinoma of Krukenberg carries a grave immediate 
prognosis. This holds true even though a relatively small primary lesion 
of the gastrointestinal tract may be removed with the metastatic ovarian 
cancer. This poor prognosis probably rests with the fact that, by the time 
the ovaries are involved, spread in the lymphatic system is extensive. 

The metastatic ovarian carcinoma of Krukenberg represents an 
advanced terminal phase of a neoplastic disease arising in the gastrointes- 
tinal tract. At this stage, treatment is usually only palliative. When 
peritoneal implants are widespread, it is apparent that radical operations, 
as presently done, are of questionable value. Under this circumstance, 
radical removal appears useless and justifiable only to relieve pressure 
symptoms, the occasional exception being those tumors arising in the large 
bowel. (Diddle, A. W. , Krukenberg Tumors: Diagnostic Problem. Cancer, 
8:1026-1030, September - October 1955) 



24 



Medical News Letter, Vol. 26, No. 9 



Deferment of Professional Examinations 

The Chief of Naval Personnel has approved the recommendation of 
the Chief of the B ureau of Medicine and Surgery to defer professional 
examinations for promotion of Medical Service Corps and Nurse Corps 
officers of the Regular Navy and Naval Reserve, 

The authority for deferment becomes effective immediately and 
extends for the remainder of Fiscal Year 1956. Official notification of 
this subject will be promulgated by the Bureau of Naval Personnel in the 
near future. {TIO, BuMed) 

Sj! * * * * * 

New Postgraduate Course Offered to 
Navy Medical Officers 

Applications are desired from Regular Navy medical officers and 
Reserve officers who have recently reported to active duty for attendance 
at a course of instruction in Preventive Medicine to be conducted at the 
Naval Medical School, National Naval Medical Center, Bethesda, Md. , 
commencing on 6 February 1956. 

Purpose . This course is offered in order to better prepare medical 
officers for their service in the Navy. It will also serve to prepare 
eligible flight surgeons of the Navy and Air Force for examination by the 
American Board. The course is designed to assure knowledge of current 
principles and practices in preventive medicine at administrative and non- 
laboratory operational levels. Of primary concern are requirements of 
the military forces, their industrial activities, and their essential rela- 
tionships with civil communities. 

Length of Course. The course covers 18 weeks of lectures, laboratory 
and field observations, seminars and individual studies. Approximately 
520 class hours are scheduled with time held in reserve for study and 
augmentation of individual subjects as found necessary. 

Instruction Personnel . Highly qualified staff personnel, augmented by 
visiting lecturers from academic institutions, the Public Health Service, 
and the other Armed Services. 

Course content includes the following: 

(a) Introduction to Biostatistic s 

(b) Epidemiology 



Medical News Letter, Vol. 26, No. 9 



25 



(c) Environmental Preventive Medicine 

(d) Health Practice - general 

(e) Health Practice - specialized fields 

Requests from interested and eligible personnel should be submitted 
via official channels to the Chief of the Bureau of Medicine and Surgery. 
Attendance will be on a temporary duty under instruction basis with travel 
and per diem provided. Enrollment is limited to 10 officers of the Navy 
plus 10 officers of the U.S. Air Force. Deadline for receipt of applica- 
tions is 1 December 1955. Reliefs cannot be provided for those approved 
for attendance. (ProfDiv, BuMed) 

****** 

From the Note Book 

1 The Secretary of the Navy approved the reports of the medical and 
dental officer promotion boards which recommended the temporary 
promotion of the following officers: 

To Captain in the Medical Corps. . . ... 283 

To Captain in the Dental Corps 303 

To Commander in the Medical Corps 381 

To Commander in the Dental Corps. . 149 

Officers selected for promotion will be issued individual appoint- 
ments when they become eligible in accordance with constructive service. 
{TIO, BuMed) 

2 CDR Gioconda R. Saraniero, MC USN, is the first woman doctor to 
be selected for promotion to the grade of Captain in the Medical Corps of 
the U.S. Navy. She is presently on duty at the Infirmary, Headquarters 
Support Activities, Naples, Italy. (TIO, BuMed) 

3 LT E. H. Gleason.MSC USN, was recently commended by the Operations 
Coordinating Board of which Herbert Hoover, Jr. , was Chairman, for his 
participation in the United States Navy's operation "Passage to Freedom, " 
during which the Navy moved 310, 848 refugees from North Vietnam. 

The Secretary of the Navy and the Chief of Naval Operations added 
their appreciation and hearty "well done" to that of the Chief of the Bureau 
of Medicine and Surgery for LT Gleason's performance in this most impor- 
tant role played by the Navy. LT Gleason, presently on duty in the Preven- 
tive Medicine Division of the Bureau of Medicine and Surgery, was serving 



26 



Medical News Letter, Vol. 26, No. 9 



on additional duty as the Public Health Officer of the Medical Task Unit 
of Task Force 90, 8. 6 during the operation. His primary duty at the time 
was on the staff of Commander, Naval Forces, Far East. (TIO, BuMed) 

4. LCDR J„ L„ Mc Clung, MC USNR, U.S. Naval Hospital, Great Lakes, 
111. , represented the Navy Medical Department at the World Congress 
of Anesthesiologists in Scheveningen, Holland, September 5 - 10, 1955. 
Doctor McClung presented a paper entitled, "Measurement of Mechanical 
and Electrical Events of the Cardiac Cycle. I. Ether Anesthesia, " as 
a part of the Section on Physiology at the Congress. (TIO, BuMed) 

5 LCDR Margaret S. Lincicome, MSC USN, became the second woman 
tc be selected for promotion to the grade of Commander in the Medical 
Service Corps when her selection to that grade was announced by the Navy 
Department on October 11. (TIO, BuMed) 

6 Class 76 of Naval Flight Surgeons was recently graduated at the Naval 
School of Aviation Medicine, Naval Air Station, Pensacola, Fla. There 
was an international note to the graduation ceremony when representatives 
of three foreign countries received their certificates. LCDR Jorge B. Lopez 
of the Mexican Navy, LT Etienne Guibal of the French Navy, and SURG LT 
Norman W. Bradford of the Royal Canadian Navy received their designations 
as Naval Flight Surgeons after successful completion of approximately 600 
hours of graduate medical training in the new specialty of Aviation Med- 
icine and 6 weeks flight indoctrination in fixed and rotary wing aircraft. 
Each of the foreign graduates returned to his country to work in the field 

of Aviation Medicine. (PIO, School of Aviation Medicine, NAS, Pensacola) 

7 A domestic water meter was coupled to a dental operating unit, the 
flush adjusted to sufficient flow, and water consumption measured for an 
eight-hour period. The water control device was then installed and the 
flow of water into the cuspidor was controlled by the patients for eight 
hours. 

Calculations based on the water meter reading indicated that the 
dental operating unit without the control device used annually 108, 247 
gallons more water than with the de vice installed. Projected into annual 
water consumption costs, the uncontrolled dental unit used 110, 518 gallons 
costing $45. 31; the same dental unit with the device installed used 2271 
gallons costing $0.93, a saving of 108,247 gallons costing $44. 38. 

8 Thirty young Indians from 12 states have entered training at Phoenix, 
Ariz. , to aid in sanitation work among their people. The course is part 
of a newly expanded program to improve health conditions among the 
American Indians and Alaskan Natives. After six weeks of intensive 



Medical News Letter, Vol. 26, No. 9 



27 



training in sanitation and hygiene, the young Indians will be assigned to 
assist Public Health Service sanitary engineers on Indian reservations 
in Arizona, Colorado, Idaho, Minnesota, Montana, New Mexico, North 
Carolina, North Dakota, Oregon, South Dakota, Wisconsin, and Wash- 
ington. (P. H. S. , Dept. H. E. W. ) 

****** 



"Good Leadership " 

"I cannot help but take this opportunity to pass on to you a little 
personal advice and word of caution with regard to your present or future 
role as a hospital commander or administrator. During the next two weeks 
you will get the very best instruction and latest approved management methods 
and everything that goes to make an efficient hospital administrator from the 
management and fiscal standpoint. This is all good, but I see some familiar 
faces before me who I know have found out long ago that it takes more than 
this to make a successful hospital commander and a good hospital. The only 
reason for the existence of any hospital is the care of patients. The best 
possible medical care for each patient should be the primary concern of 
all. In addition to the professional care there must be good morale among 
patients and those who care for them. To accomplish this there must be 
real leadership, not dictatorship. Good leadership creates optimism and 
good human and personal relations. A famous physician once achieved 
results with a strange prescription. To one of his most irritable patients 
he gave a prescription blank upon which he had written, 'Say something 
kind to somebody— anybody— three times a day, and at bed time — especially 
at bed time. ' The patient, finally convinced that the doctor was serious, 
agreed to try it. In less than a month his ulcers gave him no more trouble. 

Show me a cold impersonal hospital commander or administrator 
who enjoys the solitude of his office and the accuracy of his slide rule and 
I will show you a mediocre hospital with poor morale regardless of its fine 
management and fiscal record. Three centuries ago, the great French 
philosopher Pascal wrote, 'Kind words do not cost much. They never 
blister the tongue or the lips. Mental trouble was never known to arise 
from such quarters. Though they do not cost much, yet they accomplish 
much. They might make other people good natured. They also produce 
their own image on men's souls and a beautiful image it is. ' In your 
daily role as hospital commander or administrator don't neglect the human 
side for the business side. They are both very essential to the operation of 
any good hospital. " (Major General William H. Powell, USAF (MC)) 

(The Surgeon General recommends that all Medical Department personnel 
read and practice the above. ) 



23 



Medical News Letter, Vol. 26, No. 9 



BUMED INSTRUCTION 5720. 2A 26 September 1955 

From: Chief, Bureau of Medicine and Surgery 
To: All BuMed Management Controlled Activities 
All Internal BuMed Codes 



Subj: Newsworthy information concerning Medical Department personnel 
and activities 

This instruction establishes a regular procedure for the transmission to 
the Bureau of all newsworthy information pertaining to functions and accom- 
plishments of the Medical Department which are of general and/or special 
interest to the Navy and the public. 



****** 



BUMED INSTRUCTION 1910. 2A 8 October 1955 

From: Chief, Bureau of Medicine and Surgery 

Chief of Naval Personnel 

Commandant of the Marine Corps 
To: COMs all NavTraCens; COs all NavHosps, CLUSA: COs all 

NavRecStas, CLUSA; CGs and COs, all MarCorps Activities 

CLUSA 



Subj: Disposition of enlisted and inducted members by reason of physical 
disability or military unfitness; standards and procedures for 

Ref: (a) Physical Standards and Physical Profiling for Enlistment and 
Induction, Army Regulation No. 40-115 of 20 Aug 1948, as 
amended 

(b) Chapter 18.MMD 

(c) Title IV of the Career Compensation Act of 1949 (37 USC 
271-285) 

End: (1) Certificate relative to full and fair hearing before a 
Physical Evaluation Board 



This instruction promulgates standards and procedures for the separation 
of subject members from the Naval Service who have become functionally 
incapable of performing useful service. BuMed Instruction 1910. 2 of 
21 May 1953 is canceled. 

#*'**#)}: 

The printing of this publication has been approved by the Director 
of the Bureau of the Budget, 16 May 1955, 



Medical News Letter, Vol. 26, No. 9 



29 




ME HI CM RESERVE SECTION 



Naval Reserve Officer Schools 



At the present time, approximately 72 Naval Reserve officer schools 
with an enrollment of over 9000 inactive Reserve officers are located 
throughout the continental Naval Districts. 

Enrollment by schools ranges from 56 officers at Denver, Col. , 
to 481 at San Francisco's Treasure Island. Enrollment is open to any 
inactive duty Naval Reserve officer in good standing in the Naval Reserve. 

Courses available to Medical Department officers are Military 
Justice (2 semesters), Personnel Administration (1 semester), Leadership 
(1 semester), and Administration of Education and Training (2 semesters). 

Naval Reserve officers who are members of another Reserve unit 
may enroll. In fact, many an officer student attends one night at a Naval 
Reserve officer school and one night at the drilling unit of which he is a 
member. 

This program is essentially non-pay and is administered on the basis 
of an academic year of two semesters with classes held during September 
through June. Twenty drills a semester are scheduled (40 per year) and 
each officer must attend a minimum of 80% of the periods of instruction 
and successfully pass examinations given periodically and at the end of the 
course to complete the course satisfactorily. Both promotion and retire- 
ment points are credited to those who satisfactorily complete the courses. 
Fourteen days active duty for training with pay is available each year to 
all officers who are enrolled in Naval Reserve officer schools. 

Schools are located in the following cities of Naval Districts: 



First Naval District 



Boston, Mass. 
Lynn, Mass. 
Salem, Mass. 
Worcester, Mass. 
Portland, Me. 
Providence, R. I. 



Third Naval District 

New Haven, Conn. 
Clifton, N. J. 
Elizabeth, N. J. 
Albany, N. Y. 
Buffalo, N. Y. 
Freeport, N. Y. 



(continued) 

Huntington, N. Y. 
New York, N. Y. 

Fourth Naval District 
Cincinnati, Ohio 



30 Medical News Letter, Vol. 26, No. 9 



Fourth Naval District 

(continued) 
Cleveland, Ohio 
Columbus, Ohio 
Toledo, Ohio 
Pittsburgh, Pa. 
Villanova, Pa, 

Fifth Naval District 

Louisville, Ky. 
Baltimore, Md. 
Norfolk, Va. 
Richmond, Va. 

Sixth Naval District 

Coral Gables, Fla. 
Miami, Fla. 

Tampa-St. Petersb'g, Fla. 
Atlanta, Ga. 
Durham, N. C. 
Winston-Salem, N. C. 
Columbia, S. C. 
Knoxville, Tenn. 

Eighth Naval District 

Little Rock, Ark. 
Baton Rouge, La. 
Lafayette, La. 
New Orleans, La. 
Shreveport, La. 
Albuquerque, N. M. 
Santa Fe, N. M. 
Oklahoma City, Okla. 
Tulsa, Okla. 
Amarillo, Tex. 
Austin, Tex. 
Beaumont, Tex. 
Corpus Christi, Tex. 
Dallas, Tex. 
El Paso, Tex. 

n= * * * * 



Eighth Naval District 
(continued) 
Fort Worth, Tex. 
Houston, Tex. 
Midland, Tex. 
San Antonio, Tex. 

Ninth Naval D istrict 

Denver, Col. 
Detroit, Mich. 
Forest Park, 111. 
Evanston, 111. 
Minneapolis, Minn. 
St. Paul, Minn. 
Kansas City, Mo. 
St. Louis, Mo. 
Madison, Wis. 
Milwaukee, Wis. 

Eleventh Naval District 

Los Angeles, Calif. 
Ontario, Calif. 
San Diego, Calif. 

Twelfth Naval District 

Fresno, Calif. 
Sacramento, Calif. 
San Francisco, Calif. 
San Jose, Calif. 
Salt Lake City, Utah 

Thirteenth Naval District 

Portland, Ore. 
Seattle, Wash. 

PRNC 

Washington, D. C. (Naval Gun Fac- 
tory) and Alexandria, Va. 



Medical News Letter, Vol. 26, No. 9 



31 




PREVENTIVE MEDICINE SECTION 



Influenza Vaccination - 1955 



Influenza vaccine will be administered to all naval personnel on active 
duty in the autumn months of 1955. For optimum results, this immuniza- 
tion should be performed prior to the season of highest respiratory disease 
incidence. November 15 has been set as a desirable target date by which 
to have all influenza vaccinations completed. This season, the influenza 
vaccination will also be offered on a voluntary basis to two additional groups, 
i. e. , dependents of service personnel on active duty and civilian employees 
and their dependents who are located at overseas bases and whose medical 
care is the responsibility of the Navy. Immunization of dependents is desir- 
able because studies have shown that school age children are more suscep- 
tible to influenza than are adults and are often the source of infection of 
their parents. Adults and children, eleven years of age and older, will 
receive one subcutaneous injection. Younger children will be given two or 
three smaller injections at weekly intervals. Infants of less than one year 
will not receive this immunization. Individuals who have any history or 
suspicion of sensitivity to eggs, chickens, or feathers should not be given 
this vaccine as it is a chick-embryo-prepared virus vaccine and even the 
slightest traces of chicken protein could precipitate an anaphylactic episode 
in them. It is very important to guard this vaccine against freezing and 
also against excessively warm temperatures. It keeps best when stored 
at temperatures ranging between 35° to 50° F. (2°to 10° C. ) However, 
it may be shipped safely without refrigeration, providing that it is not per- 
mitted to freeze and is not exposed to temperatures exceeding 100° F. 
for too long a time. 

The vaccine contains a small amount of formalin, and as is frequently 
true with formalin killed vaccines, an immediate stinging sensation may be 
noticed following its injection. Also, there may be a small amount of muscle 
soreness localized at the site of injection; however, these are minor com- 
plaints and are not considered to be unfavorable reactions to the use of this 
vaccine. Prior to initiation of the influenza vaccine immunization program 



32 



Medical News Letter, Vol. 26, No. 9 



in the fall of 1954, numerous inquiries were made about reactions to the 
vaccine. Because of this, the five centers at which naval recruits are 
trained were asked to provide the Bureau of Medicine and Surgery with 
a special letter report on the incidence of reactions causing loss of time 
from duty. The reports are summarized in tabular form as follows: 



Station 


Inoculated 


Admitted 


Sick days 


Anaphylactic & 






with reaction 


(average) 


other reactions 


NTC, Great Lakes 


14, 351 


5 


1. 6 


None 


NTC, San Diego 


24, 976 


23 


2. 


None 


NTC, Bainbridge 


28, 019 


5 


4. 8 


2* 


MCRD, San Diego 


9, 230 


4 


i. 8 


None 


MCRD, Parris Island 


(unstated) 


. 0049% 


1. 


None 



Both were in individuals, sensitive to eggs, and who avoided 
being questioned prior to vaccination. 



Last year's experience demonstrated that minor local reactions 
occurred in a high percentage of individuals receiving this vaccine; however, 
little incapacitation was associated with these local reactions, and more 
severe generalized reactions occurred in a very small percentage of men. 

During the past several years, NMRU#4 has conducted studies on 
influenza including evaluation of influenza vaccines. These studies have 
been accomplished under the authority of approved research projects and 
in collaboration with the Commission on Influenza of the Armed Forces 
Epidemiological Board. The studies have been of considerable importance 
in determining the need for and results of vaccination. Additional projects 
on influenza are contemplated by NMRU #4 for the current winter season 
which will be of value in charting the influenza vaccination program of the 
future. 

It is anticipated that this vaccine will effect a substantial savings 
in money and manpower to the Navy through better health this coming 
winter. (LT John P. Egan, MC USN, PrevMedDiv) 

****** 

Influenza Vaccine Variation 

The color and general appearance of influenza vaccine may vary from 
one manufacturer to the next. One vaccine may have the color and appear- 
ance of apple cider, whereas, that of another manufacturer may be a cloudy 



Medical News Letter, Vol. 26, No. 9 



33 



white. However, all vials of this vaccine with the same lot number 
should have the same appearance. Methods of harvesting the amniotic 
fluid from the eggs and other individual details of manufacturing produce 
products with varying physical appearances but similar antigenic protective 
properties. 

$ $ $ $ $ $ 
Effectiveness of Polio Vaccine 

The quotation below is taken verbatim from the speech of Dr. Leonard 
A. Scheele prepared for presentation at the Economic Club of Detroit, 
Monday, October 3, 1955. The statement is released for publication as 
of that time. 

"The children vaccinated last year and this year are the center 
of what is probably the largest mass study of vaccine effective- 
ness in the history of public health. The Poliomyelitis Surveil- 
lance Unit of the Public Health Service, with headquarters at our 
Communicable Disease Center in Atlanta, Georgia, is serving as 
a clearinghouse for a nation-wide study to determine the effective- 
ness of poliomyelitis vaccine as used this year, and to report the 
experience of children vaccinated in the field trial. All state and 
territorial health departments and more than 30 laboratories are 
participating in the study. 

The results of this year's use of poliomyelitis vaccine cannot 
be stated precisely at the present time. The 1955 polio season 
now is just past the half-way mark, so we have only part of the 
returns on this season's occurrence of polio throughout the nation. 
There is always some lag in reporting and many weeks are needed 
to verify diagnoses and to determine the extent of paralysis in 
reported cases. We cannot compare this year's results precisely 
with the results of the 1954 field trial in which the children received 
three injections and a control group was set up by giving some 
children "placebo" shots. 

At present, we have only partial preliminary reports. On 
that basis, we cannot draw final conclusions. But I am happy to 
say that our first "returns" are very encouraging. 

Dr. Alexander D. Langmuir, who is in charge of the Public 
Health Service study I referred to, and Doctors Neal Nathanson 
and William J. Hall, members of his staff, have prepared for me 
a sort of "box-score" to date. Here it is: 



Medical News Letter, Vol. 26, No. 9 

1 The number of reported cases of poliomyelitis , paralytic 
and non-paralytic, among the 7 million vaccinated children 
throughout the United States is now running 25 to 50% below the 
incidence expected without vaccination in the same age groups. 

All states and territories are participating in this part of 
the study. During the first month or two following injections, 
about as many cases were reported in vaccinated children as 
were expected. But after the second month the frequency was 
substantially lower. Also, strong evidence of lessened severity 
became apparent after the second month when reported cases 
among vaccinated children became predominantly non-paralytic. 

2 Special studies are being carried out in nearly half of the 
states to measure the poliomyelitis experience of all children 
5-10 years of age. Early reports from six areas show that 
paralytic attack rates among vaccinated children are strikingly 
lower than among unvaccinated children of the same ages. In 
almost all reporting areas, these reductions are 50% or greater. 

3 In 29 states, where incidence has been measured by individual 
years of age, the trend is toward distinct reductions in the inci- 
dence of paralytic polio among those age groups which include 
vaccinated children. 

Preliminary analyses, based on reports of 2539 paralytic 
cases in all age groups, already show a distinct lowering of the 
incidence of paralytic polio in 8 -and 9 -year-olds, and a small 
reduction in 7-year-old children. This early evidence is sig- 
nificant because the use of poliomyelitis vaccine has been 
restricted this year chiefly to these age groups. 

4 In epidemic areas, particularly in New England and Wisconsin, 
the infrequency of paralytic cases among vaccinated children is 
notable. Especially intensive studies are being conducted in these 
states. In these high-incidence areas, the immunity of vaccinated 
children has been put to the most severe test. It is expected that 
these studies in epidemic areas will provide the most definitive 
evidence regarding the effectiveness of the vaccine this year. 

5 The number of paralytic cases among children vaccinated in 
the 1954 field trial, with or without "booster" shots this year, is 
too small for evaluation as yet. The rarity of paralytic cases in 
this group, however, is outstanding so far. 



Medical News Letter, Vol. 26, No. 9 



35 



I want to remind you again that these results are tentative. 
They are based on preliminary, and as yet incomplete, reports 
of the experience of children in limited age groups. But there 
is little likelihood that we shall see any major departure from 
the favorable trends I have reported among vaccinated children, 
although the precise x*ates may change. We will eagerly await 
the final scientific evaluations in 1956. 

It is difficult, however, not to be very optimistic about the 
value of the vaccine as used this year. The reports are all the 
more encouraging because the vast majority of these children 
have had only one injection instead of the three injections re- 
ceived by children vaccinated in the 1954 field trial. It is 
reasonable to expect even greater protection when the full course 
of immunization has been completed. 

The prospects are indeed bright for the effective control of 
paralytic poliomyelitis in the nation in 1956 and the years ahead. 
All that we know today justifies going forward as rapidly as 
possible with our vaccination program. " 

{Langmuir, Alexander D. , M. D. , Chief, Epidemiology Branch, Commun- 
icable Disease Center, P. H, S. , Dept. , H. E. W. , Special Memorandum, 
October 3, 1955) 

$ * * * $ $ 
JP-4 Jet Fuel in Eyes 
The following article may prove useful to naval activities using jet 

fuels : 

During the past month, the Naval Air Station, Columbus, Ohio, re- 
quested the Naval Fuel Supply Officer, Washington, D. C. , to supply infor- 
mation concerning the chemical content of the jet fuel JP-4. The information 
was sought for use in the treatment of personnel whose eyes may be splashed 
accidentally with the fuel, and also in the establishment of a program for the 
prevention of such accidents in the handling of the fuel. 

JP-4 fuel consists essentially of a straight run petroleum fraction, 
boiling between 150° F. to 500° F. Ordinarily it contains 10% to 18% aro- 
matic s and 20 parts per million of corrosion inhibitor, santolene. Santolene 
is essentially 50% kerosene and 50% dilinoleic acid with a controlled minor 
amount of amyl phenol partial ester of phosphoric acid. The petroleum 
fraction consists of a combination of kerosene and gasoline; if splashed into 



36 



Medical News Letter, Vol. 26, No. 9 



the eye and allowed to remain there, these compounds may cause a 
severe inflammatory reaction. The santolene portion of subject fuel 
would also produce a severe inflammatory reaction if allowed to remain 
in the conjunctival sac. Undiluted santolene placed in a rabbit's eye and 
allowed to remain there produced considerable irritation. No permanent 
damage to the rabbit's eye tissues was noted, according to information 
received from the Monsanto Chemical Company. 

JP-4 fuel, if splashed into the eyes, produces smarting and burning 
which is a typical reaction to petroleum products in general. 

Treatment should consist of immediate on-the-spot thorough flush- 
ing of the complete conjunctival sac with copious amounts of plain water. 
This procedure should be continued until it is certain that all of the fuel 
has been removed. Following this, the patient should be taken to the 
nearest medical facility, if he is not already there, for examination and 
treatment by a medical officer. 

In areas where men are exposed to potential splashes from JP-4 
fuel, personnel should be provided with, and required to wear, approved 
eye-protective equipment. 

Potable Water in Ships' Tanks 

It has come to the attention of the Bureau of Medicine and Surgery 
that in some instances water in ships' tanks has been condemned as not 
being potable on the sole basis of a high standard plate count despite a 
negative coliform count. Experiences of Preventive Medicine Units in 
judging the quality of a ship's drinking water have revealed that there is 
not sufficient evidence to warrant the assumption that standard plate 
counts are significantly related to possible contamination of the water in 
the tanks with pathogenic bacteria. On the contrary, it has been proven 
that in warm weather saprophytic bacteria can and do multiply to levels 
that often exceed bacteriological standards set forth in official publications. 

It is recommended that a ship's water tanks with high plate counts 
and negative coliform counts be neither considered unsafe nor counted in 
any series that purports to show drinking waters in naval vessels as unsat- 
isfactory. However, if doubt ever exists as to the potability of any water 
supply afloat, chlorination is recommended and should be accomplished 
immediately, as chlorination will salvage tanks of water previously con- 
demned as unsuitable. 

The methods for the determination of standard plate count of water 
supply ashore will be retained in current directives as an optional pro- 
cedure. The standard plate count of shorewater supply is considered a 
good indicator of the quality of water, and in particular, is useful in deter- 
mining the efficiency of various water treatment methods. 



Medical News Letter, Vol. 26, No. 9 



37 



Sanitary Precautions in the Handling and 
Manufacture of Ice 

Observations in the field have pointed out the need for uniform 
guidance in the health aspects of the manufacture and handling of ice. 
This information is particularly important when ice is purchased from 
commercial concerns because laws in many state and local governments 
do not consider ice a food or food product until such time as it reaches 
the food- service establishment or consumer. Consequently, ice may not 
come under regulatory control of the local or state health departments 
until such time as it enters the food- service establishment. 

Because most plants assure themselves of a safe water supply, con- 
tamination of ice is generally the result of: (1) insanitary manufacturing 
routines at the plant, or (2) handling practices while en route for delivery. 

The following precautions should be observed: 

1 The water supply should meet the same bacteriological and chem- 
ical standards set forth for drinking water in the Preventive Medicine Lab- 
oratory Methods Manual. 

2 Machines and equipment utilized in the manufacture, processing, 
and handling of ice should be kept scrupulously clean at all times. Prior 
to each period of use, each part of the equipment with which ice comes 

in contact, should be sanitized with a 200 ppm chlorine solution. 

3 Health standards applicable to other food- service personnel 
should be applied to personnel manufacturing and handling ice. Street 
clothing should not be worn in the plant, and clean, washable footwear 
should be used at all times in the pulling and handling areas. 

4 Ice should be stored in a room of satisfactory construction, 
preferably one with easily removable flooring, such as duckboards. If 
foods are stored in the same room, they should be stored off the floor and 
should neither come in contact with the ice nor be stored overhead where 
they might drip or spill to contaminate the ice beneath. 

5 Wagons, trucks, and other vehicles used for delivery of ice 
should be maintained in a clean and sanitary condition and should be com- 
pletely covered to protect the ice during transit. The inside flooring and 
body of vehicles should be washed daily, or more often if necessary, to 
maintain the surfaces in a sanitary condition. When the ice must rest 

on the floor of the truck, duckboards should be provided. 



38 



Medical News Letter, Vol. 26, No. 9 



6 Cake or block ice should be handled with tongs, and processed 
ice, in sanitary bags. Block ice should be cut in the plant to cakes not 
over 75 pounds in weight to simplify handling and storage. Ice should not 
be left on the street, sidewalk, dock, et cetera, during delivery, unless 
it is protected in a sanitary manner and then cleaned thoroughly prior to 
use. 

7 Ice to be ground or crushed should be thoroughly washed with 
potable water prior to being placed in the grinder or crusher. The grinder 
or crusher should be located in a satisfactory covered structure protected 
from airborne contamination. The containers used for delivery of the ice 
should be clean and sanitary and should be kept covered during delivery. 

If canvas containers are used, they should be washed and sanitized 
thoroughly after each us'e. The crushing or grinding of ice on trucks or 
wagons should be strictly prohibited. 

8 Cubed ice should conform to the standards for other ice. Chlor- 
ination of block, cubed, or flake ice with a 2 to 5 ppm available chlorine, 
introduced into the potable water used in the manufacture of the ice, is 
recommended to reduce bacteria and coliform counts and to act as a safe- 
guard against contamination introduced by poor processing and handling 
techniques. The same routine bacteriological examinations as those 
prescribed for potable water should be accomplished. Cleanliness should 
be observed at all times while collecting and transporting samples. 

The belief that bacteria are destroyed by freezing is disrupted by 
the fact that many bacteriologists have found in their research that disease- 
producing bacteria can survive for long periods in ice. In fact, freezing 
is now a common method of preserving cultures of some micro-organisms 
in many laboratories. 

Comparative Vascular Pathology of Occupational Ches t Diseases: 
Preliminary Observations 

Both the autopsy and biopsy findings in the lungs of persons who had 
been adequately exposed to industrial dusts, including quartz, iron, coal, 
talc, gypsum, diatomaceous earth, beryllium compounds, and asbestos, 
either singly or in combination, showed a diversity of lesions of blood 
vessels whose prevalence and extent varied according to the nature of the 
foreign substances deposited in the lungs, their quantity, and associated 
infection. The most pronounced effects were on the smaller vessels and 
comprised cellular and collagenous lesions of the capillaries in the alveolar 



Medical News Letter, Vol. 26, No. 9 



39 



walls, damage to the intima, muscular coats, and adventitia of the arter- 
ioles and venules, and perivascular deposits of pigments, fibrocytes, and 
macrophage with variable degrees of associated fibrosis. The effect on 
these small vessels may be to occlude, stenose, and distort them and to 
create inefficient vascular short circuits. Larger pulmonary vessels may 
also show damage ranging from intimal atheroma to medial segmental 
hypertrophy and collagen degeneration, cicatrical stenosis, and aneurysmal 
distention. Such vessels may become eroded and rupture. Exploration of 
the relationship between the silicotic nodule and the vascular system revealed 
that in silicosis, the vascular damage is an added lesion over and above the 
specific collagenous nodules which later may show their own peculiar vas- 
cular degenerative phenomena. In anthracosis, siderosis, berylliosis, 
talcosis, and asbestosis, the perivascular lesion proved to be an integral 
and indistinguishable component of the pathognomonic pulmonary dust lesion. 
Specific dust particles or fibers and even asbestos and tremolite bodies may, 
in most instances, be demonstrated within or in relation to these vascular 
lesions. In the presence of superimposed infection, particularly tuber- 
culosis, the vascular damage may be disproportionately great. This effect 
was found to be enhanced if there was associated quartz inhalation. Asbes- 
tosis was not observed to follow these rules directly. It is suggested that 
these vascular changes may be a factor in the genesis of cor pulmonale, 
though it is not at present established that they may bring about this result 
in the absence of associated physiological disturbances leading to anoxia. 
(Schepers, G. W. H. , Comparative Vascular Pathology of Occupational 
Chest Diseases: Preliminary Observations: A. M. A. Arch Indust. Health, 
12: 7-25, July 1955) 

* * * $ # * 

The Value of Lung Biopsy in Diagnosing 
Occupational Pulmonary Diseases 

In 26 of 66 patients, on whom surgical lung biopsy was performed 
in the course of the past 5 years at the Cleveland Clinic, a qi'.estion of 
occupational disease arose on the basis of history, roentgenologic find- 
ings, or a combination of the two. In 1 1 of the 26 patients, the lung 
biopsy finally proved a diagnosis of an occupational disease, i. e. , asbes- 
tosis in 1 patient, siderosis in 1, silicosis in 3, and berylliosis in 6. The 
cases of 2 of these 11 patients that are representative of all of them are 
reported in detail. In contrast to these 11 patients, a presumptive diag- 
nosis of occupational disease was disproved by lung biopsy in the remaining 
15 patients; presumptive diagnosis had been based on suggestive exposure 
history in 3; on suggestive roentgen- ray picture in 6; and on suggestive 
exposure history and roentgen-ray picture in the remaining 6. Three cases, 



40 



Medical News Letter, Vol. 26, No. 9 



illustrating each of these three categories, are reported. Surgical lung 
biopsy is a direct approach to the diagnosis of diffuse pulmonary disease 
in patients in whom routinely used studies fail to establish an accurate diag 
nosis. This is a particularly important procedure in borderline cases in 
which it is otherwise impossible to prove or disprove the presence of an 
occupational disease, (van Ostrand, H. S. , Effler, D. B. , McCormack, L. t 
Hazard, J. B„ , The Value of Lung Biopsy in the Diagnosis of Occupational 
Pulmonary Diseases : A. M. A. Arch. Indust. Health, 12:26-32, July 1955) 

$ sjc $ ={: £ $ 

Eyesight Saved by Safety Spectacles 

The Norfolk Naval Shipyard Industrial Health Data Sheet Report 
(NavMed 576) for July 1955 contained the following: 

"TJN, trackman, and three other employees were breaking con- 
crete with jack hammers. The men had just started to break the 
concrete when a piece approximately one inch in diameter flew up 
from the tip of one of the chisels and struck the left lens of TJN's 
safety spectacles with enough force to shatter the lens. He is 
confident that he would have sustained severe eye injury, possibly 
loss of sight, had he not been wearing safety spectacles. " 

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